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Original Investigation |

Comprehensive Geriatric Assessment and Transitional Care in Acutely Hospitalized Patients The Transitional Care Bridge Randomized Clinical Trial

Bianca M. Buurman, RN, PhD1,2; Juliette L. Parlevliet, MD1; Heather G. Allore, PhD2,3; Willem Blok, MD, PhD4; Bob A. J. van Deelen, MD5,6; Eric P. Moll van Charante, MD, PhD7; Rob J. de Haan, RN, PhD8; Sophia E. de Rooij, MD, PhD1,9
[+] Author Affiliations
1Section of Geriatric Medicine, Department of Internal Medicine, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
2Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
3Department of Biostatistics, Yale School of Public Health, New Haven, Connecticut
4Department of Internal Medicine, Onze Lieve Vrouwe Gasthuis, Amsterdam, the Netherlands
5Department of Internal Medicine, Flevo Hospital, Almere, the Netherlands
6Department of Geriatric Medicine, Kennemer Gasthuis, Haarlem, the Netherlands
7Department of General Practice, University of Amsterdam, Amsterdam, the Netherlands
8Clinical Research Unit, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
9Department of Internal Medicine, University Medical Center Groningen, Groningen, the Netherlands
JAMA Intern Med. 2016;176(3):302-309. doi:10.1001/jamainternmed.2015.8042.
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Importance  Older adults acutely hospitalized are at risk of disability. Trials on comprehensive geriatric assessment (CGA) and transitional care present inconsistent results.

Objective  To test whether an intervention of systematic CGA, followed by the transitional care bridge program, improved activities of daily living (ADLs) compared with systematic CGA alone.

Design, Setting, and Participants  This study was a double-blind, multicenter, randomized clinical trial conducted at 3 hospitals with affiliated home care organizations in the Netherlands between September 1, 2010, and March 1, 2014. In total, 1070 consecutive patients were eligible, 674 (63.0%) of whom enrolled. They were 65 years or older, acutely hospitalized to a medical ward for at least 48 hours with an Identification of Seniors at Risk–Hospitalized Patients score of 2 or higher, and randomized using permuted blocks stratified by study site and Mini-Mental State Examination score (<24 vs ≥24). The dates of the analysis were June 1, 2014, to November 15, 2014.

Interventions  The transitional care bridge program intervention was started during hospitalization by a visit from a community care registered nurse (CCRN) and continued after discharge with home visits at 2 days and at 2, 6, 12, and 24 weeks. The CCRNs applied the CGA care and treatment plan.

Main Outcomes and Measures  The main outcome was the Katz Index of ADL at 6 months compared with 2 weeks before admission. Secondary outcomes were mortality, cognitive functioning, time to hospital readmission, and the time to discharge from a nursing home.

Results  The study cohort comprised 674 participants. Their mean age was 80 years, 42.1% (n = 284) were male, and 39.2% (n = 264) were cognitively impaired at admission. Intent-to-treat analysis found no differences in the mean Katz Index of ADL at 6 months between the intervention arm (mean, 2.0; 95% CI, 1.8-2.2) and the CGA-only arm (mean, 1.9; 95% CI, 1.7-2.2). For secondary outcomes, there were 85 deaths (25.2%) in the intervention arm and 104 deaths (30.9%) in the CGA-only arm, resulting in a lower risk on the time to death within 6 months after hospital admission (hazard ratio, 0.75; 95% CI, 0.56-0.99; P = .045; number needed to treat to prevent 1 death, 16). No other secondary outcome was significant.

Conclusions and Relevance  A systematic CGA, followed by the transitional care bridge program, showed no effect on ADL functioning in acutely hospitalized older patients.

Trial Registration  Netherlands Trial Registry: NTR2384

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Figure 1.
CONSORT Diagram of Participant Inclusion

For ADL and cognition, all participants had baseline data and were included in the analyses of these outcomes. The numbers specified are those with 6-month assessment data on ADL and cognition. Nursing home discharged to community applies only for those who went directly from the hospital to a nursing home. Readmission data were only available for those who were discharged alive. ADL indicates activities of daily living; CCRN, community care registered nurse; CGA, comprehensive geriatric assessment; and CONSORT, Consolidated Standards of Reporting Trials.

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Figure 2.
Mortality From Admission to 6 Months After Admission

Shown are survival curves from a Cox proportional hazards regression analysis adjusted for study site and cognitive functioning (Mini-Mental State Examination Score, <24 vs ≥24), with the numbers of participants at risk for each 30-day interval for the intervention arm and the CGA-only arm. Significant protective intervention effects were observed for 1-month mortality and 6-month mortality. CGA indicates comprehensive geriatric assessment.

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A bridge too far? Comment on: comprehensive geriatric assessment and transitional care in acute hospitalized patients: the transitional care bridge randomized clinical trial.
Posted on June 26, 2016
W.H. Tong, MD, PhD, MSc, G. Willemsen, MD, C. Brumsen, MD
Department of Hospital Medicine, Medical Center Haaglanden – Bronovo/Nebo (MCH-Bronovo/Nebo), The Hague, The Netherlands. And Department of Internal Medicine, Medical Center Haaglanden – Bronovo/Nebo
Conflict of Interest: None Declared
We read with great interest the contribution of Buurman and co-workers. They reported lower death rates in the intervention arm, which offered a comprehensive geriatric assessment (CGA)[1] and transitional care[2], (25%) compared to the CGA-only arm (31%). Subsequently, they saw a lower risk of death within six months after hospital admission, hazard ratio (HR) of 0.75.[3] A transitional care bridge will be implemented in the vulnerable elderly national program.[4] The question, however, is what this program will solve? Therefore, we would like to respond to this article.
First, the effect of transitional care seems to start during admittance at the three study hospitals. In Figure 2 showing the Kaplan Meier curves, a deviation is already noticed at the time of discharge from the hospital in favor of the intervention arm (for instance more patients died during hospital stay in the non-intervention arm). The question arises how many deaths were “prevented” during the first two days after admittance?
Second, we would like to raise some methodological issues. It would be helpful to show the number of deaths per time point as stated in Table 1. With the use of that, the authors could present the delta change of deaths per time point to show that the patients within 30 days after discharge are the most at risk of disability. For instance, the change within 30 days after admission is 308/337 = 0.914 (intervention arm) versus 292/337 = 0.866 (CGA-only arm). Additionally, the delta change could be shown related to their baseline (before hospital discharge), but also per time point, for example: day 60 versus day 30, according to the numbers at risk. We observed that the mean and standard deviation of Katz index of activities of daily living (ADL) were almost the same, please see their Table 1. These show skewed distributions, however mixed model were used in their final analysis. Why did not the authors log-transform this Katz index of ADL? We noticed that more patients with cancer were included in the CGA-only arm. Therefore, cancer diagnosis could be a potential confounder in their calculated HRs. Have the authors tested potential confounders like sex, hospital and mini-mental state examination (MMSE) score in a multi-variate model?
Finally, Naylor and co-workers published that an advanced practice nurse-centered discharge planning and home care intervention for at-risk hospitalized elders decreased the costs of providing health care.[5] Is a systematic CGA, followed by the transitional care bridge program cost-effective?
Most importantly, geriatrics is aimed to improve quality of life, rather than to improve survival. The lower risk of death cannot be ascribed to the transitional care bridge and this program is not cost-effective. Therefore, it does not seem worthwhile for other institutions to implement the transitional care bridge program.

References

1. Ellis G, Whitehead MA, Robinson D, et al. Comprehensive geriatric assessment for older adults admitted to hospital: meta-analysis of randomised controlled trials. BMJ. 2011;343:d6553.
2. Naylor MD, Aiken LH, Kurtzman ET, et al. The care span: the importance of transitional care in achieving health reform. Health Aff (Millwood). 2011;30(4):746-754.
3. Buurman BM, Parlevliet JL, Allore HG, et al. Comprehensive geriatric assessment and transitional care in acutely hospitalized patients: the transitional care bridge randomized clinical trial. JAMA Intern Med. 2016;176(3):302-309.
4. Pronk I. In Dutch: Betere nazorg na ziekenhuis redt levens. Trouw. 2016; 16 February.
5. Naylor MD, Brooten D, Campbell R, et al. Comprehensive discharge planning and home follow-up of hospitalized elders. JAMA. 1999;281(7):613-620.





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